Two-Stage Revision for Infected Total Knee Arthroplasty: Based on Autoclaving the Recycled Femoral Component and Intraoperative Molding Using Antibiotic-Impregnated Cement on the Tibial Side.

Lee BJ, Kyung HS, Yoon SD - Clin Orthop Surg (2015)

Bottom Line:
No patient experienced soft tissue contracture requiring a quadriceps snip.This novel technique provides excellent radiological and clinical outcomes.It offers a high surface area of antibiotic-impregnated cement, a good range of motion between first and second stage revision surgery for the treatment of chronic infection after total knee arthroplasty, and is of a reasonable cost.

Affiliation: Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Daegu, Korea.

ABSTRACT

Background: The purpose of this study was to determine the degree of infection control and postoperative function for new articulating metal-on-cement spacer.

Methods: A retrospective study of 19 patients (20 cases), who underwent a two-stage revision arthroplasty using mobile cement prosthesis, were followed for a minimum of 2 years. This series consisted of 16 women and 3 men, having an overall mean age of 71 years. During the first stage of revision, the femoral implant and all the adherent cement was removed, after which it was autoclaved before replacement. The tibial component was removed and a doughy state, antibiotic-impregnated cement was inserted on the tibial side. To achieve joint congruency, intraoperative molding was performed by flexing and extending the knee joint. Each patient was evaluated clinically and radiologically. The clinical assessments included range of motion, and the patients were scored as per the Hospital for Special Surgery (HSS) and Knee Society (KS) criteria.

Results: The mean range of knee joint motion was 70° prior to the first stage operation and 72° prior to the second stage revision arthroplasty; following revision arthroplasty, it was 113° at the final follow-up. The mean HSS score and KS knee and function scores were 86, 82, and 54, respectively, at the final follow-up. The success rate in terms of infection eradication was 95% (19/20 knees). No patient experienced soft tissue contracture requiring a quadriceps snip.

Conclusions: This novel technique provides excellent radiological and clinical outcomes. It offers a high surface area of antibiotic-impregnated cement, a good range of motion between first and second stage revision surgery for the treatment of chronic infection after total knee arthroplasty, and is of a reasonable cost.

Mentions:
Using an osteotome, all cement components attached to the femoral prosthesis were removed as much as possible, after which they were washed and autoclaved at 132℃ for 30 minutes. A pack of cement was then mixed with antibiotics, and this cement paste was applied to the autoclaved femoral prosthesis, which was subsequently fixed to the femur. Another pack of antibiotic-impregnated cement was prepared and inserted in the tibia at a thickness that maintained the knee joint gap. Beads were also inserted in the intramedullary canal, if needed. To achieve joint congruency, a deep dish-like molding was made intraoperatively, by flexing and extending the knee joint. If the causative bacteria had been identified preoperatively, appropriate antibiotics were mixed with the powder component of the bone cement; however, if no causative bacteria were identified, a pack of cement (40 g) was mixed with vancomycin (4 g) and first-generation cephalosporin (4 g) before application. The bone cement used was Refobacin (Biomet Orthopaedics, Ried B. Kerzers, Switzerland), which contained 0.5 g gentamicin per pack (Figs. 1,2,3,4,5).

Mentions:
Using an osteotome, all cement components attached to the femoral prosthesis were removed as much as possible, after which they were washed and autoclaved at 132℃ for 30 minutes. A pack of cement was then mixed with antibiotics, and this cement paste was applied to the autoclaved femoral prosthesis, which was subsequently fixed to the femur. Another pack of antibiotic-impregnated cement was prepared and inserted in the tibia at a thickness that maintained the knee joint gap. Beads were also inserted in the intramedullary canal, if needed. To achieve joint congruency, a deep dish-like molding was made intraoperatively, by flexing and extending the knee joint. If the causative bacteria had been identified preoperatively, appropriate antibiotics were mixed with the powder component of the bone cement; however, if no causative bacteria were identified, a pack of cement (40 g) was mixed with vancomycin (4 g) and first-generation cephalosporin (4 g) before application. The bone cement used was Refobacin (Biomet Orthopaedics, Ried B. Kerzers, Switzerland), which contained 0.5 g gentamicin per pack (Figs. 1,2,3,4,5).

Bottom Line:
No patient experienced soft tissue contracture requiring a quadriceps snip.This novel technique provides excellent radiological and clinical outcomes.It offers a high surface area of antibiotic-impregnated cement, a good range of motion between first and second stage revision surgery for the treatment of chronic infection after total knee arthroplasty, and is of a reasonable cost.

Affiliation:
Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Daegu, Korea.

ABSTRACT

Background: The purpose of this study was to determine the degree of infection control and postoperative function for new articulating metal-on-cement spacer.

Methods: A retrospective study of 19 patients (20 cases), who underwent a two-stage revision arthroplasty using mobile cement prosthesis, were followed for a minimum of 2 years. This series consisted of 16 women and 3 men, having an overall mean age of 71 years. During the first stage of revision, the femoral implant and all the adherent cement was removed, after which it was autoclaved before replacement. The tibial component was removed and a doughy state, antibiotic-impregnated cement was inserted on the tibial side. To achieve joint congruency, intraoperative molding was performed by flexing and extending the knee joint. Each patient was evaluated clinically and radiologically. The clinical assessments included range of motion, and the patients were scored as per the Hospital for Special Surgery (HSS) and Knee Society (KS) criteria.

Results: The mean range of knee joint motion was 70° prior to the first stage operation and 72° prior to the second stage revision arthroplasty; following revision arthroplasty, it was 113° at the final follow-up. The mean HSS score and KS knee and function scores were 86, 82, and 54, respectively, at the final follow-up. The success rate in terms of infection eradication was 95% (19/20 knees). No patient experienced soft tissue contracture requiring a quadriceps snip.

Conclusions: This novel technique provides excellent radiological and clinical outcomes. It offers a high surface area of antibiotic-impregnated cement, a good range of motion between first and second stage revision surgery for the treatment of chronic infection after total knee arthroplasty, and is of a reasonable cost.